83.10 Retained Foreign Bodies and Associated Surgical Procedures in Pediatric Patients

Posted on January 26, 2017

A. L. Schwartz1, M. M. Nourian1, B. T. Bucher1  1University Of Utah,Division Of Pediatric Surgery,Salt Lake City, UT, USA

Introduction:

Retained foreign bodies (RFB) discovered after surgery are documented as an Agency for Health Care Quality and Research Patient Safety Indicator (AHRQ PSI) for hospital quality. The AHRQ PSI measures absolute numbers and is not controlled for hospital or procedure volume. Several studies have documented the contributing factors to retained foreign bodies during surgery in adults; however, there is little data in children undergoing surgical procedures. The goal of this study is to identify a cohort of children with retained foreign bodies at U.S. children’s hospitals.

Methods:

We performed a retrospective case series study of pediatric patients that underwent surgery with RFB at 49 U.S. children’s hospitals using the Pediatric Health Information System Database (PHIS) from 2004 to 2015. Patients were defined as having RFB based on the AHRQ PSI definition. Patients with RFB present on admission were excluded from the study. Patient demographics, clinical, procedural, and hospital characteristics were collected. 

Results:

There were a total of 447 post-surgical patients who were identified with RFB from 2004-2015.  The majority of patients were between 2-12 years of age (36%), male (56%), Caucasian (64%), and non-Hispanic (43%). There was an equal share between Medicaid (40%) and Commercial Insurance (46%). Admissions were equally distributed between elective (37%) and emergent (40%). As expected, the patients were high acuity with 52% requiring NICU or PICU admission and 37% requiring mechanical ventilation. At least one complex chronic condition was present in 72% of the children in the cohort. Of the 1,257 procedures performed, the majority of procedures were operations on the digestive system (22%), cardiovascular system (20%), and respiratory system (19%). The median (IQR) number of procedures per patient was 1 (IQR 1-2). The hospital length of stay for a patient with RFB was 6±20 days. The majority of patients were discharged home (86%) and the mortality rate was 2.7%. The number of RFB per hospital per year decreased from 1.8 to 0.5 during the study period.

Conclusion:

We have identified a large cohort of children with a retained foreign body after surgery based on the AHRQ PSI. The majority of children had complex chronic medical conditions and high acuity hospital admissions. The majority of procedures with a retained foreign body in pediatric patients involve operations on the digestive system, cardiovascular system, and respiratory system. This study helps define a cohort of children who are at risk for retained foreign bodies. Future studies are needed to identify patient and procedure specific factors related to RFB in children. 

 

 

83.09 With Age Comes Wisdom: Is Mother's Age Predictive of Non-Accidental Trauma in Children?

Posted on January 26, 2017

J. Green1, R. N. Damle1, G. Keefe3, J. Brady3, M. Hazeltine3, P. P. Nazarey2, M. P. Hirsh2, J. T. Aidlen2  1University Of Massachusetts Medical School,General Surgery,Worcester, MA, USA 2University Of Massachusetts Medical School,Pediatric Surgery,Worcester, MA, USA 3University Of Massachusetts Medical School,Medical School,Worcester, MA, USA

Introduction:

Non-Accidental Trauma (NAT) rates are higher when parents have unplanned pregnancy, poor prenatal care or feel a lack of community support. Young parents are likely to have limited resources, exposing them to significant stressors. We explored whether the incidence of positive skeletal survey and suspected NAT in pediatric patients correlates with maternal age.

 

Methods:  

We performed a retrospective analysis of trauma patients (<18 years old) evaluated with skeletal surveys at our institution from 2005-2015. Patients were divided into 2 groups: Mother ≤ 25 and Mother >25 years old.  Incidence of suspected NAT (defined by a child being removed from custody) was compared between groups. Statistical comparisons were performed using Chi-squared analysis or Student’s t-test where appropriate.

 

Results:

A total of 96 patients were identified for inclusion, 48 in each group.  On average, children were younger in the younger mother’s group (21 months vs. 32 months, p < 0.001). There were no differences in race, gender, injury-severity-score or level of trauma activation between groups.  A positive skeletal survey was found in 22% of all patients: 25% of those with younger mothers and 21% of those with mothers >25 (p=0.63).   Most common injury locations were head (66%), upper extremities (28%) and lower extremities (19%), with no difference between groups. NAT was suspected in 58% of patients overall, with no difference between groups (65% vs 52%, p = 0.21) 

 

Conclusion:

Following evaluation for traumatic injuries, incidence of positive skeletal survey and suspicion of NAT rates are comparable in pediatric trauma patients regardless of the mother’s age.

 

 

83.08 Outcomes following Gastroschisis Repair: Associations with Gestational Age.

Posted on January 26, 2017

J. E. Sola1, E. A. Perez1, J. Parreco1, J. Tashiro1  1University Of Miami,Surgery,Miami, FL, USA

Introduction:  We hypothesized that clinical outcomes following gastroschisis repair are related to gestational age (GA).

Methods:  We queried the Kids’ Inpatient Database (2003-2012) for infants undergoing surgical treatment of gastroschisis (ICD-9-CM procedure code 54.71). Bivariate analysis compared outcomes associated with birth at ≥37 wk, ≥35 to <37 wk, and <35 wk GA.

Results: Overall, 4,437 cases of gastroschisis repair were identified in the dataset. Infants were born at GA ≥37 wk (12%), ≥35 to <37 wk (55%), and <35 wk (33%) GA. Birth weight was most commonly 2000-2499g (39%), followed by ≥2500g (23%), and 1750-1999g (13%). Infants were most commonly Caucasian (53%) and male (51%).

 

For infants born at ≥37 wk, procedure-specific complications were 2.3 (1.3, 3.9) times more likely vs. vs. ≥35 to <37 wk GA, p=0.002. No difference in rates of wound disruption, wound infection, blood transfusion, reoperation, sepsis, pneumonia, or post-procedural hemorrhage were detected. Length of stay (LOS) did not differ significantly.

 

For infants born at <35 wk, wound disruptions were 1.6 (1.1, 2.2) times more likely vs. ≥35 to <37 wk GA, p=0.006. Blood transfusions were 1.7 (1.4, 1.9) times more likely, p<0.001. Reoperations were 1.8 (1.1, 3.1) times more likely, p=0.023. Sepsis was 1.4 (1.1, 1.8) times more likely, p=0.007. Pneumonia was 2.0 (1.0, 3.9) times more likely, p=0.037. LOS for <35 wk (57±45 days) was longer vs. ≥35 to <37 wk GA (42±32 days), p<0.001. No difference in rates of wound infection, post-procedural hemorrhage, or procedure-specific complications were detected.

Conclusion: On a comparison of gastroschisis repairs performed for infants born at full- or pre-term, complications rates are higher for infants born at <35 wk vs. ≥35 to <37 wk GA. Procedure-specific complications however, were higher for infants born at ≥37 wk vs. ≥35 to <37 wk GA. Risk-adjusted analyses will provide further detail regarding the relationship between GA and outcomes after gastroschisis repair. 
 

83.07 Pressure Ulcer Formation in Pediatric Patients on Extracorporeal Membranous Oxygenation

Posted on January 26, 2017

S. Tam1, A. Mobargha2, J. Tobias3, C. Schad4, S. Okochi1, A. Shakoor1, W. Middlesworth1, V. Duron1  1New York Presbyterian Hospital,New York, NY, USA 2Copenhagen University Hospital,Copenhagen, -, Denmark 3Columbia University College Of Physicians And Surgeons,New York, NY, USA 4Morgan Stanley Children’s Hospital of New York,New York, NY, USA

Introduction:
Critically ill pediatric patients have been shown to be at risk for pressure ulcers similar to adult patients. Associated with this are increased morbidity and length of stay, decreased quality of life, and increased hospital costs. While the incidence of pressure ulcers in patients in pediatric intensive care unit patients has been studied, there are virtually no studies addressing pressure ulcers in pediatric patients on extracorporeal membraneous oxygenation (ECMO).

Methods:
The charts of patients 21 years and younger who underwent ECMO from November 2009 to November 2015 at our Tertiary Care Children’s Hospital were analyzed. All patients developed a pressure ulcer either during their ECMO run or within 7 days of decannulation according to nursing documentation. All data was collected and de-identified from the institution’s electronic medical record. Variables of interest included type of ECMO – venovenous (VV) or venoarterial (VA), amount volume of crystalloid and blood products received during the first 7 days or during the length of the ECMO run, albumin and lactate levels on the day of ulcer formation, and whether patients were on vasopressor supportreceived steroids.

Results:
From November 2009 to November 2015, 204 patients were placed on ECMO and 10% (20) developed a pressure ulcer during their ECMO run or within 7 days of decannulation. The average age of patients was 110 ± 86 months and 60% were male. The average body surface area was 1.1 ± 0.8 m2. Most patients were placed on venoarterial (VA) ECMO (85%) and the average length of the ECMO run was 460 ± 360 hours. A majority of the decubitus ulcers were stage I (40%) and stage II (35%). Patients received a mean of 4337 ± 2609 mL of crystalloid and 4337 ± 4727 mL of blood products during the first 7 days of their ECMO run. Mean albumin on the day of ulcer formation was 3.3 ± 0.5 g/dL and lactate was 1.1 ± 0.5 mmol/L. A majority of patients were on vasopressor support during their ECMO run (70%). 

Conclusion:
This is the only observational study to date evaluating pressure ulcer formation in pediatric patients receiving ECMO. These patients are at risk of pressure ulcer formation due to their prolonged immobility and critical illness. This baseline analysis emphasizes the need for further studies identifying which risk factors are associated with ulcer development in pediatric patients on ECMO. 
 

83.06 Appropriateness and Attitudes Regarding Frozen Section Utilization in a Tertiary Children’s Hospital

Posted on January 26, 2017

F. Hebal1, M. Browne2, P. Chou1,3, N. Wadhwani1,3, M. Reynolds1,3  1Ann & Robert H Lurie Children’s Hospital Of Chicago,Pediatric Surgery,Chicago, IL, USA 2Lehigh Valley Children’s Hospital,Pediatric Surgery,Allentown, PA, USA 3Northwestern University,Feinberg School Of Medicine,Chicago, IL, USA

Introduction: Frozen Section (FS) is an essential tool that can guide intraoperative decisions directly affecting the methods and endpoint of an operation. FS analysis, however, is a multistep process prone to technical error and errors in communication. Given the technical quality of FS compared to permanent section, discordance rates between FS and final diagnosis reported in previous studies ranges from 1.4-12.9%. The potential consequences to surgical care warrants review of intraoperative FS an important component of an institution’s quality assurance process. The purposes of this study were to assess FS utilization and attitudes regarding FS of pediatric surgeons and pathologists at a stand-alone pediatric tertiary care center.

Methods: We queried hospital EMR to identify FS ordered between June 2013 and June 2014 for patients of any age. Patient medical records were reviewed to identify operative surgeons and pathologists surveyed to assess attitudes regarding FS utilization, discordance between FS and permanent section results, and communication between pathologist and surgeon. Cohen's κ  was run to determine agreement between pathologist and surgeon responses.

Results: A total of 217 FS (205 patients) were identified. Of these, 20 mislabeled FS in query, and 12 incomplete surveys were excluded, leaving 185 FS (174 patients) for analysis. Of these, the majority were in Neurosurgery 77(42%) and Pediatric Surgery 76(41%), with remaining specialties accounting for 32(17%). Pathologists felt FS a) did not impact surgical procedure in 63(34%), b) differed from final pathology in 3(2%), and c) was unnecessary in 46(25%) of cases. Surgeons felt FS a) did not impact surgical procedure in 67(36%), b) differed from final pathology in 55(30%), and c) was unnecessary in 61(33%). Analysis showed minimal-to-no agreement between pathologist and surgeon responses. Additionally, surgeons felt FS did not affect outcome in 95(51%), and verbal FS results differed from written FS results in 25(14%) of cases. Survey and analysis summarized in Table 1.

Conclusion: Effective communication and consensus between pathologist and surgeon is crucial to successful FS use in the course of surgical care. Our study demonstrates marked difference between pathologist and surgeon attitudes regarding utilization, reported results, and necessity of FS. Intraoperative FS results given verbally in OR may have contributed to discrepancy between final pathology (as perceived by surgeons) and FS (as reported by pathologists). Notably, a 21% decrease in FS orders in the year following this study may suggest a practice change in surgeon participants. Further investigation is necessary to address these findings and impact on patient outcomes.

83.05 A Review of the Treatment of Splenic Cysts at Children's Medical Center

Posted on January 26, 2017

J. Hassoun1,2, O. Gezzer3, F. Qureshi1,2  3Howard University College Of Medicine,Washington, DC, USA 1Children’s Medical Center,Dallas, Tx, USA 2University Of Texas Southwestern Medical Center,Dallas, TX, USA

Introduction The management of non-parasitic splenic cysts in children is unclear. Options include partial or total splenectomy and rarely percutaneous aspiration and sclerotherapy. The aim of this study is to assess the outcomes of these interventions.

 

Methods Retrospective review of patients <18 years with splenic cysts (2009-2016) at a major children’s hospital was performed after IRB approval. Demographics, mode of intervention and outcome data were collected. Due to the small numbers, statistical analysis was limited.

 

Results 42 patients were identified and initial management was as follows: 32 observation alone, 10 underwent intervention (4 aspiration and sclerotherapy, 6 resection). Age (yrs) was higher for intervention than observation (p=0.004, table 1). Incidental finding was the most common presentation for patients that were observed (n=30; 100%, p<0.001) and abdominal pain for intervention groups: aspiration and sclerotherapy (n=3; 75%, p=0.16), resection (n=5; 83%, p=0.05). Cyst size (cm) was larger for intervention than observation (p<0.001, table 1).

Follow up was available for 20 of the 32 observed children, 18 requiring no intervention. 2 patients failed observation and required aspiration and sclerotherapy, one at 5 months and one at 3.5yrs due to persistence of symptoms and size increase, respectively. Of the 6 children who underwent aspiration and sclerotherapy; 2 patients underwent 1 round of sclerotherapy, 2 had multiple planned rounds and 2 required multiple additional unplanned rounds of sclerotherapy. 2 patients failed sclerotherapy and underwent resection. For the 8 children who underwent resection, procedures included open splenectomy (n=2), laparoscopic partial (n=2), or complete splenectomy (n=1) and laparoscopic cystectomy (n=3). Cysts were histologically identified as epithelial (n=4), mesothelial (n=2), pseudocyst (n=1), and unknown (n=1). One small recurrence was noted in 5 of 8 patients who followed up. Based on the number of cases, statistical significance could not be computed for recurrence rate. However, aspiration and sclerotherapy required more interventions and failed more often than resection patients.

 

Conclusions Observation of splenic cysts is an appropriate management strategy for small asymptomatic splenic cysts.  Percutaneous aspiration and sclerotherapy is associated with a higher rate of recurrence while surgical resection is associated with lowest recurrence rates and should be considered for patients with large or symptomatic cysts.

83.04 An Analysis of the Online Reputations of New England Pediatric Surgeons

Posted on January 26, 2017

K. Ashok1, P. Chang2,3  1New York University,New York, NY, USA 2University Of Cincinnati,Surgery,Cincinnati, OH, USA 3Shriners Hospitals For Children-Cincinnati,Cincinnati, OH, USA

Introduction:

Physician rating websites are quickly gaining popularity. Patients are increasingly using online information to read reviews and ratings in order to choose which physician to seek care from.  Previous studies have examined the online reputation of primary care specialists.  The goal of this investigation is to find how pediatric surgeons in New England are rated and describe the online comments found on the most popular rating websites.

Methods:

HealthGrades.com, RateMDs.com, Vitals.com, UCompareHealthCare.com, and doctors.WebMD.com were chosen from those used in similar studies. The APSA website directory was consulted to find names, locations of operation, and institutions of the 77 pediatric surgeons in New England. The average rating, range, number of ratings, and comments were also logged. The overall number of ratings and weighted averages were calculated. If the doctor did not have any entries on any website, this doctor was excluded from the group averages.

Results:
Vitals.com was the most robust site, with 61 profiles. HealthGrades and UCompareHealthCare were also robust, with 57 and 35 profiles respectively. WebMDs was sparse, with only six ratings. No doctor had any average aggregate ratings below 4 out of 5. However, about one third of the surgeons had at least one rating below 4.  26.0% of the doctors had ratings from 1 to 5, 3.90% had ratings from 2-5, one doctor had a rating of 1, one had ratings from 3-5, and one had ratings from 2.5-5.  

Positive comments included "Very professional" and "THE best pediatric surgeon."  Negative comments included "arrogant butcher", "wouldn't send a dog to be treated by him."

Conclusions:
Average ratings for the pediatric surgeons were for the most part very high (> 4) on average.  However, the average number of ratings was low for the vast majority of surgeons for most of the sites examined.  The comments left on the sites tended toward hyperbole but could emotionally affect potential patients seeking information about their prospective surgeon.  Pediatric surgeons need to be aware of their online reputation.
 

83.03 Skeletal Survey and its Role in Identifying a Non-Accidental Mechanism in Pediatric Trauma Patients

Posted on January 26, 2017

J. Green3, R. N. Damle3, M. Hazeltine2, G. Keefe2, J. Brady2, P. P. Nazarey4, M. P. Hirsh4, J. T. Aidlen4  2University Of Massachusetts Medical School,School Of Medicine,Worcester, MA, USA 3University Of Massachusetts Medical School,General Surgery,Worcester, MA, USA 4University Of Massachusetts Medical School,Pediatric Surgery,Worcester, MA, USA

Introduction:

Skeletal survey is the imaging modality of choice to diagnose skeletal injury in Non-Accidental Trauma (NAT) victims under 2 years. Infants less than 6 months old are potentially the most vulnerable. We explore the utility of skeletal survey in our youngest trauma patients and its frequency of injury detection of NAT.

 

Methods:  

A retrospective analysis of pediatric trauma patients (<18 years old) with a skeletal survey was performed at our institution from 2005-2015. Patients were divided into 2 groups: ≤6months and >6months to 3 years. Chi-squared analysis or Student t-test were performed when appropriate.

 

Results:

Our study identified 184 patients (98 patients were ≤6 months, 86 were >6 months to 3 years). There were no differences in race, gender, injury-severity-score or level of trauma.  A positive skeletal survey was found in 16% of patients: 14% ≤6months and 19% >6months (p=0.43). Most common fractures identified on skeletal survey were long bone (24%), torso (15%), and skull (6.7%), with no statistical difference between groups.  NAT was suspected in 58% of patients, with no difference between groups (58% vs. 57%, p=0.78).  Head computed tomography(CT) scans were performed in 96% of patients ≤6 months old and just 66% of the patients older than 6 months (p<0.01).

 

Conclusion:

Skeletal surveys identify additional injuries at comparable rates in pediatric trauma patients regardless of age. Pediatric trauma patients 6 months old or younger are more likely to receive a head CT scan as part of their trauma workup.

 

83.01 Gastrointestinal Outcomes of Patients with Omphalocele

Posted on January 26, 2017

P. E. Lau1, C. S. Bernardo1, O. O. Olutoye1,2, D. L. Cass1,2, S. M. Cruz1, T. C. Lee1,2, S. Nuthakki2  1Baylor College Of Medicine,Pediatric Surgery,Houston, TX, USA 2Texas Children’s Hospital,Pediatrics,Houston, TX, USA

Introduction: Perinatal management of patients with giant omphaloceles(GO) can be challenging  and be associated with mortality and morbidity. The purpose of this study was to assess the gastrointestinal outcomes in these patients, specifically time to attaining full enteral and oral feeding milestones.

Methods: We performed a retrospective chart review of patients with omphalocele from 1/2003 –2/2014. Patients were classified into isolated, omphalocele with minor or major anomalies categories. Major anomalies were defined as a cardiac defect requiring immediate medical or surgical treatment, congenital diaphragmatic hernias, and major chromosomal abnormalities. All other anomalies were classified as minor. Giant omphalocele was defined as >50% of liver in the sac. Feeding milestones were defined as the time to attain 120 ml/kg/d of enteral/oral feeds. We also evaluated length of stay, days on mechanical ventilation, need for tracheostomy, days of TPN, use of motility agent and achivement of full oral feeds prior to discharge.

Results:Of 82 live born patients, 53 survived to discharge. Patients with major anomalies had significant longer length of stay, delayed feeding milestones and were less likely to feed orally compared to patients with minor and isolated omphaloceles(Table 1). Respiratory morbidity of patients with major anomalies was more severe as shown by a higher rate of tracheostomies and longer length on mechanical ventilation. Patients with GO(n=25) had longer length of stay(36vs13, p=0.002), took longer to reach full enteral feeds(22vs10 days, p=0.015), had more days of TPN(17vs10 day, p=0.022). Fourteen(56%) of the patients with GO did not reach full PO feeds compared to six(21%) in the other group(p=0.045). Three(12%) patients with GO had G-tubes and six(24%) patients required motility agents. No motility agents or G-tubes were observed in non-giant omphalocele group.        

Conclusion:The presence of major anomalies and GO appears to be a strong predictor in prolonging the achievement of full enteral feeds with obvious need for longer duration of TPN. Patients with isolated omphaloceles and patients with minor anomalies achieved full oral feeds at similar times, length of stay is longer with minor patients. This is likely related to the poor pulmonary status of these patients. Patients without GO are less likely to be treated with motility agents or need a g-tube. These findings are important for counseling parents and for the design perinatal interventions to improve outcomes on these patients.

82.20 Sarcopenia is a predictor of postoperative morbidity and mortality in elderly with esophageal cancer

Posted on January 26, 2017

Y. Nakashima1, H. Saeki1, R. Nakanishi1, M. Sugiyama1, J. Kurashige1, E. Oki1, Y. Maehara1  1Kyushu University,Department Of Surgery And Science,Fukuoka, FUKUOKA, Japan

Introduction:
The present study investigated the effect of sarcopenia on short-and long-term surgical outcomes and identified potential prognostic factors for esophageal cancer among patients 65 years of age and older.

Methods:
Patient data were retrospectively collected for 341 consecutive patients who underwent esophagectomy for esophageal cancer. Patients were assigned to two groups according to age (younger than 65 years and 65 years and older), and the presence of sarcopenia. The clinicopathological, surgical outcome, and long-term survival data were analyzed.

Results:
Sarcopenia was present in 170 of 341 patients (49.9%) with esophageal cancer, and 48.5% of patients aged 65 years and older. The incidence of anastomotic leak and in-hospital death were significantly higher in elderly sarcopenia group than in elderly non-sarcopenia group (30.1% versus 16.3%, 6.8% versus 0.0%, respectively). Overall survival rate in patients with sarcopenia correlated with significantly poor prognosis in the group aged 65 years and older (p<0.001). Multivariate analysis revealed that sarcopenia was predictive of anastomotic leak and unfavorable prognosis in the group aged 65 years and older. On the other hand, both of the incidence of surgical complications and overall survival rate were similar between sarcopenia and non-sarcopenia in patients younger than 65.

Conclusion:
This retrospective analysis revealed that sarcopenia was a risk factor for anastomotic leak and a prognostic marker of overall survival after esophagectomy in patients 65 years of age and older with esophageal cancer.
 

82.19 Reconstruction and Functional Status Following Surgical Treatment of Foot Melanoma

Posted on January 26, 2017

G. M. Winter1, J. D. Vargo2, J. M. Mammen3  1Unversity Of Kansas,School Of Medicine,Kansas City, KS, USA 2University Of Kansas,Department Of Plastic Surgery,Kansas City, KS, USA 3University Of Kansas,Department Of Surgery,Kansas City, KS, USA

Introduction:

Melanoma of the foot is often challenging to diagnose and treat due to its subungual, palmar and/or plantar locations. Patients with foot melanomas often present late, after significant radial spreading of malignant cells, and require more extensive resections. Following excision, reconstruction should reflect the functional and weight bearing nature of these locations. However, little is known about the reconstructive strategies needed for patients with melanomas of the foot. This study evaluates a series of patients with foot melanomas to identify disease thickness at time of diagnosis, extent of excision, reconstructive method, and functional status.

Methods:

After IRB approval, a retrospective review was performed to identify all patients with foot melanoma who underwent surgical excision at our institution between January 2010 and May 2016. Following identification, patient charts were reviewed for relevant demographic information, lesion location, tissue diagnosis, Breslow thickness, excision area, exposed structures, reconstructive method, functional status, complications, and survival. Reconstruction was performed either by the primary surgeon or in conjunction with plastic surgery and was determined based upon defect size, location, and exposed structures.  Functional status was determined by the number of days between reconstruction and clearance for weight bearing activities. 

Results:

34 patients met inclusion criteria (21 women and 14 men). Mean patient demographics and lesion characteristics were as follows: age 63±15, BMI 28.2±6.0, Breslow Thickness 2.0±1.8 mm, and excision area 35.5±25.6 cm2. Reconstructions were performed as follows: 11 Full thickness skin grafts (FTSG), 8 split thickness skin grafts (STSG), 7 Integra with STSG, 2 local flaps, 3 primary closures, 2 secondary healing, and 1 DIP amputation. 28 of 34 patients had complete data on functional status. Functional status recovery based on reconstruction were as follows: 23 days for FTSG, 17 for STSG, 29 for Integra with STSG, 35 for local flaps, 6 for primary closure, 8 for secondary healing, and 7 for amputation.

Cellulitis was seen following 3 STSG only, and P. aeruginosa infection was seen following 1 Integra and STSG reconstruction. One death occurred during the study period due to systemic progression of melanoma. Median follow up was 11 months.

Conclusion:

This study demonstrated the utility of a variety of reconstructive options following excision of foot melanoma. FTSG was most commonly used to reconstruct defects of plantar surfaces when there was a healthy wound bed with no exposed tendon or bone. When these structures are exposed, Integra placement with subsequent STSG is a viable option with good result. Functional status was regained first by STSG, then by FTSG, and finally by Integra and STSG. Ability to regain functional status is found to be dependent on reconstruction method.

82.18 Reconstruction of Major Defects after Oncologic Resection: An Institutional Review

Posted on January 26, 2017

K. P. Walsh1, G. Grimberg1, A. J. Scholer1, L. J. Lynch1, J. D. Keith2, R. J. Chokshi1  1New Jersey Medical School,Division Of Surgical Oncology, Department Of Surgery,Newark, NJ, USA 2New Jersey Medical School,Department Of Plastic Surgery,Newark, NJ, USA

Introduction:  Oncologic resections vary in size and technical difficulty due to a multitude of factors: oncologic process, margin needed, surrounding structures involved and subsequent defect size.  After an extensive resection, many surgeons are challenged by the reconstruction due to both the size of the defect and the vital structures that are exposed.  The purpose of this study was to review our institution’s experience with oncology-related resection and subsequent reconstruction in patients with extensive defects. To date, this is the largest series examining oncology-related resection and subsequent reconstruction in adults.

Methods:  We conducted a retrospective review of 95 adult patients who underwent both an operative resection by a surgical oncologist and a subsequent reconstruction by plastic surgery at our institution over a four-year period from 2012 to 2015. Patient demographics were characterized, and an analysis of both the oncologic resection and subsequent reconstructive operations was performed.

Results:  The cohort consisted of 95 patients with a mean age of 52.7 (26-87) years old and mean BMI of 27.8 (16-46). The majority of our patients were smokers (51.6 %) and had significant medical comorbidities (56.8 %). Of the resections, 66% were for malignancy. The most common malignancies were:  adenocarcinoma of the GI tract (22.2 %), sarcoma (15.9 %), squamous cell carcinoma (15.9 %) and basal cell carcinoma (12.7 %). The sites of resection included the trunk (44.2 %), extremities (31.6 %) and head & neck (24.2 %). Major defects (>225 cm2) were encountered in 38.9 % of patients, with a mean defect size of 240 cm2. Many reconstructive techniques were employed, including primary/complex closure (10.1 %), skin graft (10.1 %), adjacent tissue transfer (14.7 %), pedicled flaps (29.5 %) and free flaps (34.7 %). The most frequently used free flap was an anterolateral thigh flap (60.1%), and common pedicled flaps included rectus abdominis (34.2 %), gracilis (13.2 %) and gastrocnemius flaps (10.5 %).

Conclusion:  Radical oncologic resection and subsequent reconstruction of large defects can be safely and effectively performed using a multi-disciplinary approach. Collaborative efforts between surgical oncology and plastic surgery have enabled patients with significant medical comorbidities to undergo a variety of successful oncologic resections with subsequent effective reconstruction of major defects.

 

82.17 Optimal Timing for Surgery following Neoadjuvant Cheomradiation in Patients with Rectal Cancer

Posted on January 26, 2017

N. Ghalyaie1, K. S. Goodman2, C. S. Lau2,3, R. S. Chamberlain2,3,4  1Banner MD Anderson Cancer Center,Surgery,Gilbert, AZ, USA 2Saint Barnabas Medical Center,Surgery,Livingston, NJ, USA 3Saint George’s University,Grenada, Grenada, Grenada 4Rutgers University,Surgery,Newark, NJ, USA

Introduction:  Surgery and either neodadjuvant or adjuvant therapy is the gold standard treatment for rectal cancer.  Advances in fluoropyridine-based neoadjuvant chemoradiation (NCR) regimens have resulted in a high percentage of rectal cancer patients exhibiting a complete pathologic response (pCR) after proctectomy. This implies that a subset of patients may be able to undergo surveillance and ultimately not require proctectomy.  This study sought to examine the impact of the time between completion of NCR and definitive surgical therapy on the likelihood of a achieving a pCR.

Methods:  A comprehensive literature search of PubMed, Google Scholar, Medline, and the Cochrane Central Registry of Controlled Trials (1966-2016) was conducted.  Keywords searched included rectal cancer, neoadjuvant chemoradiation, and surgery, and only articles written in English were included. The outcome analyzed was the incidence of pCR.

Results: 13 studies involving 2,731 patients with stage I, II, or III rectal cancers were included. Studies ranged from neoadjuvant chemoradiation completed 41 days prior to surgery to 12 weeks prior to surgery. 13 of the studies reported higher pCR rates following extended intervals (>6-8 weeks) between neoadjuvant chemoradiation and surgery, 5 of which were statistically significantly. Results ranged from 27.1% – 34.5% for extended intervals, compared to 15.3% – 27.3% for shorter intervals (<6-8 weeks) between neoadjuvant chemoradiation and surgery. 

Conclusions:  Neoadjuvant chemoradiation is capable of achieving a pCR in 15 – 34.5% of patients with rectal cancer.  The optimal interval between NCR and surgery is controversial, however, prolonging the interval time between neoadjuvant cheomradiation and surgery (>6-8 weeks) may increase the chance of pCR, especially with Stage II and III rectal cancer. Additional studies evaluating which specific patients (eg.,T2 N0-2, or T3 N0-2) are most likely to achieve pCR, and the impact of a  prolongation in the interval between NCR and definitive surgical therapy is needed.

 

82.16 Clinical Characterization of Pancreatic Sarcoma: A Longitudinal Single Institution Experience

Posted on January 26, 2017

C. V. De Carvalho Fischer1, H. N. Overton1, C. L. Wolfgang1, C. Meyer2, F. M. Johnston1, N. Ahuja1  1Johns Hopkins University School Of Medicine,Department Of Surgery,Baltimore, MD, USA 2Johns Hopkins University School Of Medicine,Medical Oncology,Baltimore, MD, USA

Introduction:

Primary pancreatic sarcoma is a rare intra-abdominal neoplasm with relatively unknown survival rates due to limited reports in the literature. We present the only known case series of pancreatic sarcoma from a single-institution 15 year experience and aim to compare to previously reported retroperitoneal sarcoma overall survival (OS) and recurrence free interval (RFI) at the same institution. 

Methods:

Retrospective analysis of all primary pancreatic sarcomas at Johns Hopkins Hospital from 1990 to 2015. Overall survival and recurrence free interval after surgical resection was determined using the Kaplan-Meier method on GraphPad Prism 6.   

Results:

Pancreatic sarcoma patients were an average age of 57.8 years (+/- 13.62) at diagnosis. Liposarcomas were the most common histological tumor type, affecting six of eighteen patients with primary sarcomas of the pancreas. Other histology included leiomyosarcoma or GIST phenotype, epitheloid angiosarcomas and fibrosarcomas of the pancreas, and malignant spindle cell tumor. On average, the largest diameter of the tumor was 11.92cm (+/- 8.32). The tumor was classified as high grade in eight cases whereas only four cases were described as low or intermediate grade malignancies. The tumor grade remained undefined in six cases. Only two out of eighteen sarcomas were deemed unresectable. The remaining patients had surgical interventions, out of which 55.56% (10/18) underwent a Whipple procedure, and 33.33% (6/18) underwent a distal pancreatectomy. Pathology reports defined eight cases as having achieved a R0 resection, four of eighteen with R1 resections and two of eighteen with R2 resections. The median overall survival of this collective was 32 months whereas the median recurrence free interval following surgical resection was 14 months. In comparison, recent analysis of retroperitoneal sarcoma outcomes treated at the Johns Hopkins Hospital within the same time period demonstrated overall survival of 48.7 months and recurrence free survival of 20 months. Given the small smaple size in the case series of pancreatic sarcoma, analysis of variables important in survival, such as grade and resection status, could not be performed.

Conclusion:

Pancreatic sarcoma demonstrated decreased overall survival and recurrence free survival after surgical resection when compared to retroperitoneal sarcoma treated at the same institution. Though a rare tumor type, the data presented warrants further research on pancreatic sarcoma.

82.15 Propensity Matched Analysis of Infection Rates in Wide Local Excision of Melanoma

Posted on January 26, 2017

D. R. Ziazadeh2, E. L. Kalbfell2, R. N. Matar2, S. Mauch2, L. R. Mohey2, J. L. Parker3, M. Melnik1,2  1Spectrum Health,Surgical Oncology,Grand Rapids, MICHIGAN, USA 2Michigan State University,College Of Human Medicine,Grand Rapids, MICHIGAN, USA 3Spectrum Health,Biostatistics & Research,Grand Rapids, MICHIGAN, USA

Introduction: Wide local excision is the current gold standard for patients diagnosed with histologically confirmed cutaneous melanoma. There is no published consensus on the infection rate for common melanoma surgeries. We set out to evaluate the rate of infection in adult patients in wide local excision of melanoma.

Methods: From 11/19/2011 to 11/18/2014, adult patients 18 years and older underwent wide local excision of melanoma at Spectrum Health. The primary outcome variable was presence or absence of infection at surgical site. Clinical patient characteristics and data were extracted from our local electronic medical record. Patients were propensity matched for age, gender, BMI, smoking status, autoimmune diseases, and diabetes yielding 21 well-matched pairs. Operative data collected included method of infection diagnosis, site and size of excision, procedures, complications, histological results and melanoma classification.

Results: A total of 200 patients were identified. Of these, 23 developed a post-operative infection (12.2%) after melanoma excision. Infection sites differed, with 12 occurring at the site of wide local excision, 10 at the site of lymph node biopsy, and one at the skin graft site. 60.8% of those infected were diagnosed clinically and 39.2% were culture confirmed. There was no significant difference in age (61±17 vs 58±17 yr), gender (61±49% vs 43±51% male), BMI (29±7 vs 33±9 kg/m2), history of smoking (35±48% vs 48±51%), autoimmunity (7±25% vs 4±21%), or diabetes (18±39% vs 22±42%) before propensity matching in non-infected vs infected patients. Table 1 summarizes pertinent operative factors and comorbidities on rates of infection after propensity matching. Infection rate varied by specialty: Surgical Oncology, 12.4% (19/153), Plastic Surgery, 8% (2/25), and General Surgery, 7.4% (2/27) respectively.

Conclusion: In wide local excision of melanoma, surgical time, excisional size, Breslow Thickness, and Clark Level provided equivalent clinical outcomes on the rate of infection. Future analysis is pending regarding the impact of histological stage/grade, LNB location, and wound closure on the rate of infection.

 

82.14 Let’s cut the Core; When is Core Biopsy Enough for Sub Centimeter Breast Cancer?

Posted on January 26, 2017

B. Shea1, W. Boyan1, K. Kamrani1, G. Lepis2, S. Chang1, M. Goldfarb1, D. Dupree1, M. Kohli1  2St. George’s University School Of Medicine,St. George’s, St. George’s, Grenada 1Monmouth Medical Center,Surgery,Long Branch, NJ, USA

Introduction:  

Breast conservation therapy has become a preferred method of treating early stage breast cancer by many surgeons and patients. Multiple trials have shown similar survival rates with less invasive surgery to both the breast and axilla thanks in part to adjuvant therapies and a better understanding of breast cancer biology. As care continues to evolve, different sizes and types of lesions are allowed less invasive treatment options. A relatively simple explanation of early breast cancer care is detection, biopsy, surgery and adjuvant therapy. The authors in this article look to challenge that algorithm for a specific type of disease. 

Methods:

A single institution retrospective review was performed to identify all patients over the last five years who have undergone breast biopsy for malignant or pre-malignant lesions. Of these, 115 met the requirements of being less than one centimeter at detection and undergoing the traditional treatment algorithm outlined above. These cases were analyzed for biopsy technique and outcome of final surgical excision to find when no residual disease was found upon final pathology because the entire lesion was removed by the initial biopsy. 

Results:

The authors found that seventeen of 115 patients (14.8%) who underwent biopsy for sub cm breast cancer had no residual disease found on final surgical resection. Neither size of biopsy sample nor size of the lesion correlated with having no residual disease on surgical resection. Although size of needle also didn’t reach statistical significance, the smallest needle biopsies were never found to have no residual disease (ten patients) on final pathology while biopsies with the largest 7 gauge needle was found to have negative pathology in two out of three patients. 

Conclusion:

This study looked at 115 patients that were diagnosed and treated for sub cm breast cancer in the standard: detection, biopsy, surgery pathway. The authors thought that sub cm lesions represents a unique subset of breast cancer that presents a plethora of questions. If the ever shrinking margins can be obtained with a biopsy needle, what benefit does a formal resection provide? Many lumpectomies result in comparatively large resections for a small lesion, causing cosmetic distress. Although 14.8% is not a large portion of the samples, this number was obtained when radiologists were merely trying to get a sample of tissue for diagnosis. If sub cm lesions could be treated with a larger needle and effort to resect the whole mass, the yield could be much higher. Prospective protocol based trials would be needed to truly see how much sub cm breast cancer is truly left after biopsy alone. 

82.13 Long Term Survival After Resection of Sarcomatoid Carcinoma of the Pancreas: An Updated Experience

Posted on January 26, 2017

A. Blair1, R. Burkhart1, J. Griffin1, J. Miller2, M. Weiss1, M. Makary1, J. Cameron1, C. Wolfgang1, J. He1  2Johns Hopkins University School Of Medicine,Department Of Pathology,Baltimore, MD, USA 1Johns Hopkins University School Of Medicine,Department Of Surgery,Baltimore, MD, USA

Introduction:
Sarcomatoid carcinoma of the pancreas (SCP) is a rare histologic subtype of undifferentiated pancreatic carcinoma. Historically this has been associated with worse overall prognosis than adenocarcinoma. However, owing to the rarity of the disease, clinical course and surgical outcomes remain poorly characterized.

Methods:
A single-institution, prospectively maintained database was queried for patients who underwent pancreatic resection with a final diagnosis of SCP. We describe their histology, clinicopathologic features and perioperative outcomes. Survival data is highlighted and common traits of long-term survivors are examined.

Results:
Over a 15-year period, 7009 patents underwent pancreatic resection at our institution. Eight (0.11%) were diagnosed with SCP on final histopathology as determined by a predominance of spindle cells and sarcomatoid features with epithelial derivation. Further histologic subtyping demonstrated two cases with the presence of osteoclast like giant cells (OCGC). Mean patient age was 67 years and three patients were males (37%). Lesions were equally distributed between the head and the body/tail of the pancreas. R0 resection was achieved in six patients (75%) (Table 1). Four patients had early recurrence leading to death (<3 months). There were no deaths attributed to perioperative complications. Two (25%) experienced long term-survival (>5 years), with the longest surviving nearly 16 years despite the presence of lymph node metastasis at the time of operation. There were no long term survivors amongst those with OCGC identified on histopathology. Both long term survivors had disease in the body/tail of the pancreas and received adjuvant radiotherapy. One (50%) also received additional adjuvant gemcitabine based chemotherapy.

Conclusion:
S SCP is a rarely appreciated subset of pancreatic malignancy with bimodal outcomes. While many have rapid disease recurrence that leads to their early demise, a diagnosis of SCP does not necessarily portend to a uniformly dismal prognosis. Long-term survival is possible. Future studies are needed to better define the cohort with potential for long-term survival so that aggressive therapies may be tailored appropriately in this patient subset.

82.12 Medullary carcinoma thyroid in the RET era

Posted on January 26, 2017

D. Abraham1, A. Cherian1, R. Pai2, S. Chakravarthy1, P. Jacob1  1Christian Medical College, Vellore,Endocrine Surgery,Vellore, TAMIL NADU, India 2Christian Medical College, Vellore,Molecular Pathology,Vellore, TAMIL NADU, India

Introduction:  The management of medullary carcinoma thyroid (MTC) has evolved to incorporate gene testing. We conducted this study to evaluate the impact of RET mutation testing in the management of MTC.

Methods:  Retrospective study of data between January 2008 and December 2015 from the computerised hospital information system was analysed using STATA (v.10).

Results: MTC accounted for 89/1877(4.7%) patients with thyroid cancer. The mean age of presentation was 39.6 years (range of 14-70) with M:F=48:41. Three patients presented with a pheochromocytoma, four were screen detected and the remaining had goitre. FNAC was diagnostic in 67.6% while calcitonin was elevated in 94.9%.RET testing was performed in 69 patients, 24 were positive (34.8%).Seventeen relatives of ten index patients were screened and twelve were RET positive. Patients with hereditary MTC were younger (34.9 vs 39.3) with a female preponderance (M:F = 8:16).Prophylactic thyroidectomy was performed in 3 patients. All patients underwent primary surgery. Persistent hypercalcitoninemia (calcitonin > 50pg/ml) was observed in 50/78(64.1%). Of these, 41 patients underwent metaiodobenzylguanidine scan, three were positive. The median duration of follow up was 14 months. Twelve patients were lost to follow up and two patients succumbed to their disease.

Conclusion:  MTC accounts for 5% of thyroid carcinoma in our series. Hereditary MTC presents at an earlier age than the sporadic type with afemale preponderance. RET screening should be performed for all patients with MTC as they may be the index case and prophylactic surgery may be offered for those children testing positive.

 

82.11 Screening High-Risk Pancreatic Subjects Leads to Acceptable Detection Rates of Precancerous Findings

Posted on January 26, 2017

J. T. Wiseman1, R. Hendrix1, W. Y. Wassef2, K. Flores3, A. Friedrich1, K. Dinh1, E. Rouanet1, G. Whalen1, J. LaFemina1  1University Of Massachusetts,Surgical Oncology,Worcester, MA, USA 2University Of Massachusetts,Gastroenterology,Worcester, MA, USA 3University Of Massachusetts,Pediatrics,Worcester, MA, USA

Introduction:  Pancreatic ductal adenocarcinoma (PDAC) is the 3rd most common cause of cancer death in the United States. As there is no definitive impact of screening on cure, the role of screening high risk cohorts remains controversial. Furthermore, no gold standard screening pathway has been established. Herein we present our initial experience, focusing on the radiologic and endoscopic findings of high-risk subject screening.

Methods:  Subjects were eligible if they were determined to be at intermediate or high personal risk for PDAC as determined by one of the following: personal/family history of a genetic syndrome associated with PDAC; personal history of chronic pancreatitis of unknown etiology; or family history of PDAC. Subjects were recruited from May 2013-November 2015. The screening and evaluation algorithm is summarized in Figure 1.  Analysis is conducted on the radiologic and endoscopic pancreatic findings in all new patients. Subjects with known PDAC were excluded. 

Results: Sixty-eight patients were analyzed during the study period. The average age was 55 years (range: 22-82 years) and 78% were female gender. There were 43 (63%) subjects who completed an MRCP or CT-scan of the abdomen. Fifty-three (78%) subjects completed an endoscopic ultrasound. Precancerous cyst(s) were found in 16% of subjects; 50% were newly diagnosed. Chronic pancreatitis was found in 65% of subjects; 32% were newly diagnosed.

Conclusion: We demonstrate that in a moderate/high-risk population for PDAC, the rate of detecting precancerous findings is acceptable and greater than expected. While it is too early to determine the current impact of a successful screening protocol for PDAC on survival, we believe early diagnosis will lead to earlier treatment and subsequent improvement in patient outcomes.

 

82.10 Pre-Surgical Imiquimod Cream Reduces Extent of Moh’s Surgery on Basal Cell Carcinoma of Head and Neck

Posted on January 26, 2017

H. Foong1, N. Shaikh1, H. Liang1, D. Yakoub1  1University Of Miami,Division Of Surgical Oncology At Department Of Surgery,Miami, FL, USA

Introduction: Extent of surgery for BCC in the face continues to be a cosmetic challenge. Moh’s micrographic surgery is successful in reducing that extent with equal oncologic results. We aimed to evaluate the role of pre-surgical 5% Imiquimod cream application in reducing defect size. 

Methods: Online database search of PubMed, MEDLINE, EMBASE, SCOPUS, COCHRANE, and GOOGLE SCHOLAR was performed; key bibliographies were reviewed. Studies comparing patients using preoperative 5% Imiquimod followed by surgery to those who had surgery alone were analyzed. The primary end point was defect size at surgery for similar sized tumors. Relative risk with the corresponding 95% confidence intervals (CI) were calculated by random effect models of pooled data. Study quality was assessed using STROBE criteria. 

Results:27 Articles were identified, amongst those, 3 studies met our selection criteria. Mean BCC size was 92.42mm2. Most common histologic type was nodular. Average lesion size was 227.8mm2. Meta-analysis of included data showed that application of 5% Imiquimod cream one time daily, 5 days/week for 4 weeks significantly reduced the defect size of the Moh’s micrographic surgery resection with a combined mean difference of -80.37 mm2 (95% CI: -106.67, -54.08, P<0.001). A regimen of similar frequency for 6 weeks showed similar trend compared to 4 weeks, yet did not achieve statistical significance with an additional mean difference of -10.24 mm2 (95% CI: -31.68, 11.20, P=0.35).

Conclusion:5% Imiquimod cream application in BCC of the face, using a regimen of 4 weeks may reduce the defect size of the Moh’s micrographic surgery.

 

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