69.02 Bad Surgeons or Bad Data? A Review of Patient Safety Indicators Attributed to Trauma Surgeons

Posted on January 26, 2017

N. Fox1, R. Willcutt1, A. Elberfeld1, J. Porter1, A. Mazzarelli1  1Cooper University Hospital,Trauma,Camden, NJ, USA

Introduction: The Agency for Health Care Research and Quality (AHRQ) developed patient safety indicators (PSIs) to identify events with a high likelihood of representing medical error. They are increasingly used by health systems as quality measures that impact public profiling and compensation. The purpose of this study was to validate PSIs attributed to trauma surgeons and compare validated PSIs to our performance improvement (PI) and morbidity and mortality (M&M) data. We hypothesized that PSIs are not an indicator of quality of care in trauma. 

Methods: PSI’s attributed to trauma surgeons (n=9) at our institution were reviewed (Jan-Dec 2015). A documentation improvement team performed an initial review of all PSIs to ensure they were correctly identified and met inclusion and exclusion criteria (valid). “Valid” PSIs were distributed to the trauma division for review and compared to PI and M&M data.

Results:2,779 patients were admitted during the study period. 48 PSIs were identified (17.2 per 1000 cases). 23 were false positives yielding a positive predictive value of 52% (95% CI 37 to 66%). Contributing factors to false positive PSIs were coding error (78%), present on admission status (17%) and documentation error (5%). Valid PSIs (n=25) were further analyzed.  The most common were post-op PE/DVT (n=10), failure to rescue (n=6) and accidental puncture/laceration (n=3). 60% of patients with a post-op PE/DVT were started on appropriate chemoprophylaxis on admission and 40% had significant intracranial hemorrhage (not candidates for immediate chemoprophylaxis); therefore all were determined to be non-preventable through trauma PI.  All deaths considered failure to rescue were classified as expected mortalities during M&M review. All cases classified as accidental puncture/laceration (6% of valid PSIs) were considered accurate and represented the only opportunity for improvement.

Conclusion:Overall, PSIs have low validity and do not reflect quality of care in trauma. Trauma PI and M&M data along with chart review should be used to identify true opportunities for improvement in care.

 

69.01 Age and Facility Disparities in Resuscitative Thoracotomy Attempts

Posted on January 26, 2017

K. Lynch1, P. Bonasso1, R. Whitehair1, A. Wilson1, D. Long1, J. Con1  1West Virginia University,Department Of Surgery,Morgantown, WV, USA

Introduction:
Resuscitative thoracotomy (RT) is an operation of last resort performed on moribund trauma patients. RT carries a risk of disease transmission and has a low survival rate, so the decision to attempt RT can be difficult. We hypothesize that disparities exist in RT attempt rates based on age and facility characteristics. 

Methods:
The 2008-12 National Trauma Data Bank (NTDB) dataset was queried to identify patients who underwent open chest cardiac massage within one hour of arrival to the ED. Three groups were isolated: survived RT, died after RT, and died in the ED without RT. Patients were stratified by age and facility characteristics after adjusting for blunt or penetrating injury mechanism. Attempt rate was calculated by dividing RT attempts by all candidates for RT. We defined the survival rate as patients who survived RT divided by all those who underwent RT.

Results:
The overall RT attempt rate was 10.9% (18.1% penetrating, 6.3% blunt). Disparities in age stratified attempt rates were identified and are summarized in Table 1. RT survival was 5.5% (6.4% penetrating, 3.9% blunt), and no significant differences in age stratified survival rates were observed. RT attempt rates were higher at ACS Level 1 or 2 Trauma Centers, at university hospitals, at larger facilities, and certain regions in the country (Table 1). Increasing facility size correlated with improved RT survival after penetrating trauma.

Conclusion:
RT survival rates among elderly blunt trauma patients were similar to other age groups, yet attempt rates were significantly lower. This suggests a provider bias against this age group. For penetrating injuries, poor survival rates in the elderly were accompanied by appropriately low attempt rates. Attempt rates were higher at large university hospitals and at Level 1 or 2 Trauma Centers possibly because of the educational benefit of performing them. Further studies examining provider bias in patient selection for RT are needed.

68.10 Surgical Experience and the Practice of Pancreatoduodenectomy

Posted on January 26, 2017

G. T. Kennedy1, M. T. McMillan1, M. Sprys1, J. A. Drebin1, C. M. Vollmer1  1Hospital Of The University Of Pennsylvania,Philadelphia, PA, USA

Background:  Surgeons with greater experience have demonstrated improved outcomes following pancreatoduodenectomy (PD), but little is known about what distinguishes their practice. Furthermore, the concept of experience has been variably interpreted in the surgical literature—some authors prioritize years in practice while others delineate cumulative career procedure volume or annual practice productivity. We sought to identify how these various forms of surgical experience influence management decisions for PD.

 

Methods: A survey assessing PD experience and practice patterns of pancreatic surgeons was distributed by six international gastrointestinal surgical societies. Questions regarding the practice patterns of individual surgeons were presented using a modified Likert scale. Multivariable, stepwise logistic regression analysis identified factors associated with three different forms of experience: years in practice, surpassing the PD learning curve (≥50 PDs), and high annual PD volume (≥25 PD/year).

 

Results: The median career PD volume of the 861 respondents was 80 (Interquartile range: 30-200). With regard to years in practice, forty-four percent of the surgeons were early-career (≤10 years of practice following training), 30% mid-career (11-20 years), and 26% senior-career (>20 years). Senior surgeons were more likely to use pancreatogastrostomy, dunking/invagination, external stents (all P<0.05). In terms of career total volume, the PD learning curve was surpassed by only 65% of respondents. Fewer early-career surgeons (39%) have attained this threshold compared with mid-career (80%) and senior-career (89%) surgeons (P<0.00001). Regression analysis identified factors independently associated with surpassing this learning curve of ≥50 cases (Table). Regarding annual productivity, surgeons in the upper quartile of annual PD volume (≥25/year) also demonstrated certain practice patterns; they were more likely to use the isolated roux limb technique (P=0.044) and the same type of pancreatico-enteric reconstruction on every case (P=0.016), but less likely to use autologous tissue patches (P=0.003) and multiple drains (P=0.0002).

 

Conclusion: The concept of experience in pancreatoduodenectomy encompasses several components: years of practice, attainment of the learning curve, and annual productivity. Each of these notions appear to influence decision-making during this complex operation in different ways. 

68.09 Guideline Adherence in Screening Mammography: Behavior Patterns in Commercially-Insured U.S. Women

Posted on January 26, 2017

J. Yu1, N. P. Carlsson1, G. A. Colditz1, M. S. Goodman1, S. Chang1, J. A. Margenthaler1  1Washington University,Surgery,St. Louis, MO, USA

Introduction:
Over 2 million women currently live with breast cancer in the United States, and the annual incidence of more than 200,000 new cases is predicted to remain constant.  Secondary prevention of breast cancer with screening mammography has become the standard of care, but recent updates in recommended screening mammography frequencies have ignited substantial controversy both among physicians and from a societal perspective.  To better understand the potential impact on patients, we assess guideline adherence in a retrospective cohort of commercially-insured U.S. women diagnosed with breast cancer.

Methods:
Using the Truven Health Analytics|MarketScan®|Database from 2006-2012, we conducted a retrospective review of screening mammography frequencies in women aged 40-60 during the 5 years prior to primary breast cancer diagnosis, excluding ductal carcinoma in situ (DCIS), in 2011-2012.  Patient demographics, family history, and clinical characteristics were extracted from the database, and screening adherence was defined as annual (<14 months) and biennial (<26 months).  Unadjusted and multivariable analyses were performed, with two-sided statistical testing. Statistical significance was determined using α =0.05.

Results:
Of 1,876 women diagnosed with breast cancer in 2011-2012, mean age at diagnosis was 53.7±4.3 years, and patients underwent an average of 5.2±2.4 mammograms (2.7±1.7 screening, 2.0±1.4 diagnostic) prior to diagnosis.  Only 16.4% were adherent to annual screening vs. 51.6% adherent to at least biennial screening.  In the adjusted multivariable analysis, odds of adherence to either annual or biennial screening were significantly increased with family history of breast cancer (OR=1.74 [95% CI=1.30-2.32]; OR=1.50, [95% CI=1.19-1.89]), decreased with higher Klabunde Charlson comorbidity score (OR=0.89 [95% CI=0.82-0.97]; OR=0.92 [95% CI=0.87-0.97]), and unaffected by insurance provider (OR=0.77 [95% CI=0.57-1.0]; OR=1.14 [95% CI=0.91-1.43]) or geographic region (OR=0.98 [95%CI=0.68-1.40]; OR=1.08 [95% CI=0.82-1.42]).

Conclusion:
Biennial screening mammography recommendations will likely result in higher rates of guideline adherence.  In this retrospective cohort, more than triple the number of women included were adherent to biennial vs. annual screening; even so, nearly 50% of commercially-insured U.S. women diagnosed with breast cancer in 2011-2012 were not adherent to even biennial screening prior to diagnosis.  Further assessments of resource utilization and long-term outcomes will be critical to determine appropriate population health intervention methods to increase screening compliance.
 

68.08 Survival In Breast Cancer Associated With Drug Sensitive Or Resistant-related MiRNAs Using TCGA

Posted on January 26, 2017

J. S. Young1, T. Kawaguchi1, L. Yan2, Q. Qi2, S. Liu2, K. Takabe1  1Roswell Park Cancer Institute,Department Of Surgical Oncology,Buffalo, NEW YORK, USA 2Roswell Park Cancer Institute,Department Of Biostatistics And Bioinformatics,Buffalo, NEW YORK, USA

Introduction: MicroRNAs (miRNAs) are short (19-25 nucleotides) noncoding RNAs, which have been discovered to exert function through the degradation or inhibition of mRNA translation. Dysregulation of miRNAs has been identified to play a critical role in carcinogenesis and breast cancer progression. Some miRNAs are reported to be associated with drug sensitivity, while others are associated with drug resistance. In this study, several miRNAs known to be related to the sensitivity or resistance of different breast cancer drug treatments were evaluated for association with overall survival using The Cancer Genome Atlas (TCGA).  This included miR-221/222 related to tamoxifen (TAM), miR-30a related to Taxol/doxorubicin (TAX/DOX), miR-210 related to trastuzumab, miR-342 related to tamoxifen, miR-328 related to mitoxantrone, miR-326 related to VP-16/doxorubicin/MIT, miR-487a related to MIT, and miR-31 related to staurosporine/DOX.

Methods: All clinical datasets were obtained from The Cancer Genome Atlas (TCGA). MiRNA-seq data were retrieved from the GDC data portal to evaluate known drug resistance or sensitivity-related miRNAs (miR-221/222, miR-30a, miR-210, miR-342, miR-328, miR-326, miR-487a, and miR-31) and correlate them clinically to survival. Patients were separated into groups based on high and low expression of miRNA-specific thresholds and survival plots were generated using a Cox proportional hazard model.

Results: Among the 1097 breast cancer cases logged in TCGA, 1053 cases were found to contain appropriate data for analysis. Patients with high expression levels of miR-342, reported to be related to TAM sensitivity, have  increased overall survival (p=0.035). Patients with high expression levels of miR-30a, reported to be associated with TAX/DOX sensitivity, have significant increased overall survival (p=0.032). Patients with high expression levels of miR-31, reported to be associated with staurosporine/DOX sensitivity, have significant increased overall survival (p=0.038) as well. However, miR-328, miR-326, miR-487a, and miR-210 have previously been reported to have some association with increased response to chemotherapy.  In our analysis using TCGA data, they did not show any significant association with overall survival. Surprisingly, high expression levels of miR-221 and miR-222, thought to be related to TAM resistance, demonstrated significant increased overall survival (p=0.047, 0.032, respectively).

Conclusion: Although the role of miRNAs is important in drug sensitivity and resistance, its impact on survival should be validated using large clinical databases such as TCGA.
 

68.07 The validity of omega-3 fatty acids for patients on chemotherapy for biliary or pancreatic cancer.

Posted on January 26, 2017

K. Abe1, T. Uwagawa1, Y. Nakaseko1, K. Haruki1, Y. Takano1, S. Onda1, F. Suzuki1, M. Matsumoto1, T. Sakamoto1, T. Gocho1, S. Wakiyama1, Y. Ishida1, K. Yanaga1  1The Jikei University School Of Medicine,Department Of Surgery,Minato-ku, TOKYO, Japan

Introduction: Previous studies have reported that omega-3 fatty acids inhibit the production of inflammatory cytokines, which show positive impact on several cancer-related cachexia. However, such studies are rarely reported in biliary or pancreatic cancer. Since patients with pancreatic cancer often suffer from exocrine pancreatic insufficiency, the ingestion of omega-3 fatty acids with digestive enzyme supplements may improve nutritional state of such patients. In this study, we prospectively investigated the efficacy of nutritional support by omega-3 fatty acids for the patients receiving chemotherapy for unresectable biliary or pancreatic cancer, and addition of by pancreatic digestive enzyme for pancreatic cancer patients.

Methods: Patients who underwent chemotherapy for unresectable  biliary or pancreatic cancer between November 2014 and May 2016 were prospectively enrolled in this study. The enteral nutrient Racol®, which includes omega-3 fatty acids, was administered at a dose of 2 to 4 packs (1 pack contains 200 kcal/300 g of omega-3 fatty acids) per day. Parameters were measured pre-administration, and at 4 and 8 weeks after the administration. Patients with pancreatic cancer underwent pancreatic function diagnostant (PFD) test. Then, these patients were given the pancreatic digestive enzyme supplement Lipacreon® (150 mg, 12C/day) for 4 weeks starting 4 weeks after initiating the enteral nutrient. This study was approved by the Institutional Review Board (IRB), and all patients provided written informed consent before participating in this trial.

Primary outcome measures: Body weight and skeletal muscle mass. Secondary outcome measures: Blood test data (EPA concentration, EPA/AA ratio, Glasgow prognostic score, RTP, neutrophil count, IL-6, natural killer cell activity, HbA1c, CEA, and CA19-9).

Results: Twenty-two patients were enrolled. No adverse effects were observed in the patients studied. In all 22 patients, there was a significant increase from pre-administration value  in skeletal muscle mass (p=0.004 and 0.001, respectively) at 4 weeks and 8 weeks and in body weight at 8 weeks (p=0.031).

For 14 patients with pancreatic cancer, significant increase in muscle mass was observed at 4 and 8 weeks (p=0.020 and 0.032, respectively). However, there was no significant difference between the muscle mass at 4 and 8 weeks. As for body weight and other parameters, there was no significant difference.

Conclusion: Nutritional support with omega-3 fatty acids for the patients receiving chemotherapy for unresectable biliary or pancreatic cancer increased skeletal muscle mass and improved cancer-related cachexia, while additional pancreatic digestive enzyme was not associated with increase in skeletal muscle mass or body weight.
 

68.06 Colorectal Cancer Outcome Disparities Increase with Distance from Treating Facility

Posted on January 26, 2017

S. P. Beierle1, J. McLoughlin1, R. Heidel1, L. Gregory1, M. Casillas1, A. J. Russ1  1University Of Tennessee Graduate School Of Medicine,Surgery,Knoxville, TN, USA

Introduction:  Outcomes for colon cancer have improved over the last thirty years due to improved emphasis on screening and better treatment options.  However, various regions of the United States remain below the expected outcomes for colon cancer.  We hypothesized that rural counties especially in the Appalachian region had worse outcomes for colon cancer and the reasons may be multi-factorial. 

Methods:  We queried the National Cancer Database (NCDB) for all patients diagnosed with an invasive colon cancer from 2008 – 2013.  A total of 712,172 patients were identified in the database.  We focused on the South Atlantic and West South Central States which included the states and counties within the defined Appalachian region. We analyzed clinical and pathologic features, socioeconomic factors, distance, and outcomes. Tests for normal distribution, Odds ratio, and Logistic regression were performed.

Results: Of the 712,172 patients identified, we focused on 186,700 patients in the South Atlantic and West South Central states with invasive colon cancer. After accounting for variations in insurance coverage, age, race, income, education, and comorbidities; living beyond 20 miles from the treating hospital increased the likelihood of presenting with metastatic disease (p<0.001).   Having no insurance was an independent predictor of presenting with metastatic disease (p<0.001). When evaluating for race , African Americans were 27% more likely to present with metastatic disease at diagnosis than whites [OR 1.27 (p= <.001, 95% CI = 1.234-1.309)]. Additionally the 30 day mortality was higher for African Americans than Caucasians (OR 1.288) and much higher for Charleson Deyo scores of 1 or 2 (OR 6.3 and 7.6). When comparing comorbidities using the Charleson Deyo score, having a known comorbidity corresponded with a decreased likelihood of presenting with metastatic disease at diagnosis (OR 0.837 for 1 comorbidity) and (OR 0.828 for 2 or more comorbidities) (P<.001 for both).

Conclusion: In summary, distance from the treating medical facility as an indicator of rurality confirmed rural communities remain a marker for worse colon cancer outcomes compared to urban communities.  Those with no insurance, distance > 20 miles from the treating hospital and African-American race correlated with worse outcomes. Our results suggest that rural communities are undergoing insufficient screening tests for colon cancer given the higher risk of presenting with metastatic disease.  Further, the risk of presenting with advanced disease decreased with increasing comorbidities further suggesting a lack of medical access for those in rural communities.  

 

68.05 Transplant Offers Survival Benefit Over Resection for Patients with HCC and Preserved Liver Function

Posted on January 26, 2017

J. B. Liu1,2, T. B. Baker4, N. Suss3, M. S. Talamonti2,3, K. K. Roggin2, D. J. Winchester2,3, M. S. Baker2,3  1American College Of Surgeons,Chicago, IL, USA 2University Of Chicago,Chicago, IL, USA 3Northshore University Health System,Evanston, IL, USA 4Northwestern University,Chicago, IL, USA

Introduction:
Prior studies from large national datasets comparing transplantation and resection for hepatocellular cancer (HCC) have not appropriately controlled for liver function. Previous multi-institutional series comparing transplantation and resection have included small numbers of patients with preserved liver function while also including those with decompensated cirrhosis. The benefit of transplantation relative to resection in patients with preserved liver function and potentially resectable HCC continues to be subject of considerable debate. 

Methods:
We evaluated patients from the National Cancer Data Base (NCDB) undergoing treatment for HCC between 2010 and 2013 with calculated MELD scores <11. Patients undergoing resection were 1:1 propensity-matched to patients undergoing liver transplantation based on age, gender, comorbidity burden, tumor size, tumor multiplicity, pathologic stage, margin status and MELD score. Logistic regression models with robust standard errors were constructed to examine 30- and 90-day mortality. Unadjusted and adjusted survival analyses were conducted using Kaplan-Meier and shared frailty models.

Results:
2,463 patients underwent operative management for HCC. Patients undergoing resection were more likely to have positive resection margins than those undergoing transplantation (7.0% vs. 0.3%, p <0.0001). After propensity matching, 854 patients were included in our study: 427 underwent resection and 427 underwent transplantation. Rates of 30- (1.9% vs 1.9%, p = 1.00) and 90-day mortality (3.3% vs 3.0%, p = 0.85) were identical between matched cohorts. Median follow-up was 551 days for those undergoing resection and 607 days for those undergoing transplantation. Patients undergoing resection demonstrated lower rates of overall survival relative to those undergoing transplantation in unadjusted analysis (median overall survival 39% vs not reached, p < 0.0001, log-rank test)  and an increased risk of death in shared frailty models (hazard ratio 2.21 [95% confidence interval 1.54-3.17]).

Conclusion:
Individualized care models are the cornerstone of treatment pathways for patients with HCC. In the subset of those with preserved liver function, there is active controversy as to whether resection or transplant offer superior overall survival rates for these patients. This propensity matched analysis of a large national database demonstrates a clear survival advantage for transplantation. Further prospective randomized clinical trials are needed to validate these findings.
 

68.04 A Fast and Frugal Decision Tree Model to Predict Opioid Adverse Events Following Oncologic Resection

Posted on January 26, 2017

S. A. Brownlee1, S. G. Pappas2, L. A. Gil1, A. Cobb1,2, P. C. Kuo1,2, A. N. Kothari1,2, G. J. Abood2  1Loyola University Medical Center,One:MAP Division Of Clinical Informatics And Analytics,Maywood, IL, USA 2Loyola University Medical Center,Department Of Surgery,Maywood, IL, USA

Introduction: Pain management is a crucial aspect of cancer care, particularly in patients undergoing surgical tumor resection. An increasing awareness of the potential hazards of opioid use, coupled with the high rate of opioid utilization by cancer patients, necessitates further study of risk factors for opioid-related adverse events in patients undergoing oncologic resection. The objective of this study was to construct a simple decision tree model to predict patients likely to experience an opioid-related adverse event following an oncologic resection.

Methods: The Healthcare Cost and Utilization Project (HCUP) State Inpatient Database (SID) and State Emergency Department Database (SEDD) from the state of California for the years 2006-2011 were linked to define the population of interest. Patients undergoing one of four elective oncologic resection procedures (esophagectomy, lung lobectomy, hepatic resection, and colectomy) were included for study. The primary endpoint was an opioid-related adverse event during the year following surgery. A fast and frugal decision tree was constructed to predict the factors that most contributed to the occurrence of an opioid-related adverse event.

Results:  148 699 patients undergoing one of four oncologic resection procedures in CA during 2006-2011 met inclusion criteria. Of these, 230 (0.2%) experienced an opioid-related adverse event in the year following the procedure. Recursive partitioning analysis of the cohort revealed age, income, length of stay after procedure, and comorbidity index as the most significant predictors of opioid-related adverse event, with age being the strongest predictor. For patients less than 63 years old, income level was the next strongest predictor of an opioid event.

Conclusions: Though rare, opioid-related poisonings and adverse events are serious complications for cancer patients undergoing surgical resection. Through the use of four readily-obtainable patient variables (age, income level, length of stay, and comorbid disease burden), this simple prediction model may provide clinicians with a practical tool to help decrease the frequency of opioid-related adverse events in a particularly vulnerable population.  

68.03 Impact of Endocrinologist and Surgeon Density on Thyroid Cancer Survival

Posted on January 26, 2017

A. D. McDow1, W. E. Zahnd1, P. Angelos2, N. Lanzotti1, J. D. Mellinger1, S. Ganai1  1Southern Illinois University School Of Medicine,General Surgery,Springfield, IL, USA 2University Of Chicago,Endocrine Surgery,Chicago, IL, USA

Introduction:  

Thyroid cancer is the most rapidly increasing malignancy in the United States. Prior analysis of rural-urban differences in population-level thyroid cancer incidence and survival revealed that lower incidence rates were seen in rural counties, which were also associated with significantly lower survival. In this study, we sought to evaluate the impact of provider density on outcome. We hypothesized that survival would be improved for patients living in counties with greater density of endocrinologists and/or thyroid surgeons.

Methods:  
An observational study was performed on 90,286 patients who underwent surgical management of follicular and papillary thyroid cancer using the Surveillance Epidemiology and End Results (SEER) database from 2000-2012. United States Department of Agriculture Rural Urban Continuum Codes were used to categorize counties as urban or rural. Density of general surgeons and otolaryngologists (i.e., the number of potential thyroid surgeons), as well as the density of endocrinologists per 100,000 residents were calculated per county. Multivariable Cox regression analysis was used to assess the relationship between provider density and cause-specific survival controlling for demographic, socioeconomic, and treatment characteristics.

Results: 

Patients were 78.5% female, 91.3% resided in urban counties, and 55.5% were over 45 years old. 70.6% presented with localized disease and 85.9% underwent total thyroidectomy. Median endocrinologist density was 1.4 per 100,000 and surgeon density was 14.8 per 100,000. 15.5% of patients lived in a county without an endocrinologist and only 1.7% lived in a county without a surgeon. Decreased survival was noted for those living in counties below the median density of surgeons (Log rank p=0.02) and endocrinologists (p=0.004). Cox regression analysis demonstrated endocrinologist density was significantly associated with improved survival (HR 0.89; 95% CI, 0.82-0.97; p=0.007), suggesting that an increase in one endocrinologist per 100,000 people improves survival odds by 11%. Living in a rural county (HR 1.29; 95% CI, 1.07-1.56; p=0.009), age greater than 45 years (HR 13.00; 95% CI, 10.20-16.58; P<0.001), male gender (p<0.001), and advanced stage (p<0.001) were also independently associated with lower survival. There was no significant association between surgeon density and survival (HR 0.99; 95% CI, 0.98-1.00; p=0.06). 

Conclusion: 

This study demonstrates that endocrinologist density is significantly associated with improved survival in patients with follicular and papillary thyroid cancer.  There was no association between surgeon density and survival, although this variable may not reflect the impact of surgeons with a focused interest in thyroid or endocrine surgery. The findings may reflect the importance of an endocrinologists’ role in diagnosis and treatment of thyroid cancer, or as a surrogate marker for counties with better overall access to care.

 

68.02 Indications for the Use of Total Parenteral Nutrition in Patients Undergoing Pancreaticoduodenectomy

Posted on January 26, 2017

C. E. Worsh1, T. Tatarian1, A. Singh1, M. J. Pucci1, J. M. Winter1, C. J. Yeo1, H. Lavu1  1Thomas Jefferson University,Department Of Surgery, Jefferson Pancreas, Biliary And Related Cancer Center,Philadelphia, PA, USA

Introduction:  Total parenteral nutrition (TPN) has historically been used conservatively in the management of patients undergoing pancreaticoduodenectomy (PD). In this study, we set out to identify the indications for and outcomes associated with TPN use in a high volume pancreatic surgery center.

 

Methods:  With IRB approval, we retrospectively queried our institution’s pancreatic surgery database and identified patients who received TPN after undergoing PD from 2006 through 2015.

 

Results: Of 1246 patients who underwent PD, 232 (19%) received TPN perioperatively. Sixty-seven percent were male and 50% had a soft pancreas. The most common postoperative complications requiring the initiation of TPN were delayed gastric emptying (DGE, n=131, 56%), pancreatic fistula (n=51, 22%), and generalized malnutrition (n=25, 11%). The median day of TPN initiation was POD 4 (range: minus 31 to 22), with a median usage of nine days (range: 1 to 115), at a cost of $650 to $950 per day. Forty-four (19%) patients were on TPN for a short period of time (three days or less), primarily those diagnosed with isolated DGE without associated complications (p=0.02). On upper GI examination, short-term TPN patients predominately had evidence of anastomotic edema (p=0.03), whereas patients on long-course TPN therapy (>3 days) tended to show evidence of gastric aperistalsis. Seventy-seven percent of TPN patients underwent postoperative CT imaging, of which half were found to have drainable intraabdominal fluid collections, predominately those on long-term TPN therapy (p=0.0012). Hyperglycemia (glucose >200 mg/dL, 34%) was the most common complication resulting from TPN use, while central line infections (3%) were rare. Readmissions (35%) were most commonly due to poor oral intake (27%). The 30-day mortality rate in the overall TPN cohort was 3.4% compared to our institutional no-TPN rate of 0.8%.

 

Conclusions: In modern PD surgery, TPN use is a critical and safe adjunct to aid in the rescue of patients from postoperative complications. However, an opportunity exists to limit TPN overuse by avoiding initiation in patients who have DGE secondary to anastomotic edema and focusing TPN use to patients who have additional PD associated complications such as pancreatic fistula or intraabdominal fluid collections.

 

 

68.01 The Short and Long-term results of Laparoscopic, Open hepatectomy for HCC

Posted on January 26, 2017

M. Huang1, C. Chin-An1  1Taipei Medical University – Shuang Ho Hospital,Surgery,New Taipei City, SELECT A STATE/PROVINCE, Taiwan

Introduction:  

  We started to performed laparoscopic technique to treat liver tumor in 2001. After a series of modifications during surgical procedures, laparoscopic liver resection became the first choice for HCC, if the tumor is not large in size or near the hilar region in our hospital. For major or difficult area resection, the technique of approach was started with hand-assisted laparoscopic method then shift to laparoscopic assisted (hybrid) method and changed to pure laparoscopic method in 2009. Furthmore, we developed a unique technique, “ Transumbilical single incision laparoscopic approach” for tumor in superficial portion of liver in 2011. 

Method:

  Between Oct 2006 and Sep 2011 (period I), 54 patients with HCCunderwent LLH  and 37with HCC compatible patients received open method. Laparoscopic approaches included 26 laparoscopic partial resections, 18 laparoscopic left lateral segmentectomies , 10 received one or two segmentectomies and one received right lobectomy. From Oct 2011 to Dec. 2015 (Perioid II), 142 patients with HCC received pure LLH and expanded to advanced stage. The pathology group was 71 patients in stage I, 48 patients in stage II and 23 pateints in stageIII. BIn the period II, there were 19 patients underwent SILH for HCC in the peripheral portion of liver and 48 compatible patients received LLH. The short and long term results of various stage LLH was analysted with open hepatectomy.

Results:    

The short-term outcom of LLH for HCC :

   In the period I, the laparoscopic group has the advantage of less operating time (142 min VS 193 min), less intraoperative blood loss (359 ml VS 580 ml) and shorter hospital stay (7.3 days VS 10.3 days).  There is no difference in surgery-related complication rate. In the period II, the SILH group posed less operating time (86 min VS 139 min), less intraoperative blood loss (94 ml VS 120 ml) and shorter hospital stay (4.0 days VS 6.5 days). 

 

The long-term effect of LLH for HCC

  In the period I, the 1-year, 3-year and 5-year survival rates was comparative in these two group, 98%, 77%, and 72% in the laparoscopic group and 94%, 82 % and 70% in the open group, respectively, and the 1-year, 3-year and 5-year disease free rates were 94%, 70% and 60% in the laparoscopic group and 72%, 53% and 23% in the open group. In the period II, The 1-year, 3-year and 5-year survival rates was comparative 90%, 81%, and 79%; and the 1-year, 3-year and 5-year disease free rates were 73.5%, 58.5% and 47.6%.

Conclusion

  LLH can be performed safely and seems to offer at least short-term benefits for patients with HCC and achieve comparable results and acceptable oncological outcomes as open procedure. SILH a safe procedures and takes more advantages over LLH in term of less operation time, fewer blood loss and shorter hospital stay. SILH is also an alternative choice for patients with small HCC in the peripheral segment of liver requiring limited resection.

67.10 Comparing Pathological T stage with Next Generation Sequencing in Melanoma

Posted on January 26, 2017

L. Selesner1, M. Renzetti1, I. Soliman1, H. Wu1, B. Luo1, A. Olszanski1, S. Movva1, M. Lango1, S. Reddy1, F. Zih1, J. M. Farma1  1Fox Chase Cancer Center,Surgical Oncology,Philadelphia, PA, USA

Introduction:  Molecular profiling of primary cancers is becoming an important technique to evaluate and personalize treatment for patients with melanoma.  We have investigated mutations in 50 different targetable cancer-related genes using Next Generation Sequencing (NGS). This study uses molecular profiling data to examine the relationship between these mutations and the pathological primary thickness in a cohort of patients with malignant melanoma. 

Methods:  A retrospective study of a prospective dataset was performed that included patients with both primary and recurrent malignant melanomas (MM). From this cohort of patients, we analyzed tissue samples for somatic mutations in targeted regions of 50 cancer-related genes. Clinical and pathological data was collected. Statistical analysis was performed to identify mutations based on the pathological T stage of the primary tumor. The mean number of mutations per person presenting at each T stage was then investigated.

Results: We collected specimens from 135 patients with melanoma. The median age of diagnosis was 65 years (range 24-90) and 63.7% were male (n=86). At last follow up, 64 had no evidence of disease, 46 were alive with disease, 20 died of disease, 2 died of other causes, and 3 had an unknown status. Of the tissues tested, 4 presented as pathological T stage 1 (3.5%), 26 as T stage II (22.6%), 33 as T stage III (28.7%), and 50 as T stage IV (43.5%). At T stages I, II, III, IV averages of 1.75, 1.19, 1.78 and 1.62 mutations per person were attained (p= 0.44). Among the mutations found, NRAS and BRAF mutations were frequently expressed in each of the T stages. Of the patients presenting as T stage I, 50% had a NRAS mutation (n=2). At T stage II, 30.8% of the patients had a NRAS mutation (n=8). At T stage II, 42.8% had a NRAS mutation (n=14) and at T stage IV, 26% of the patients had the mutation (n=13) (p=0.52). In reference to BRAF, 25% of the T stage I patients (n=1), 34.6% of the T stage II patients (n=9), 24.2% of the T stage III patients (n=8), and 22% of the T stage IV patients (n=11) had a mutation in at least one of the BRAF genes (p=0.71). Also of interest, TP53 was the most common mutation in the patients presenting at T stage IV with 28% of this cohort expressing this mutation (Figure 1).

Conclusion: Using our NGS platform in patients, we identified the most prevalent mutations in our cohort of patients that presented at the four different pathological T stages (I-IV). We found that for T stage I, the most frequent mutation was in NRAS. For T stages II and III, mutations in NRAS and at least one of the BRAF genes, were expressed in the highest number. Finally, TP53 and NRAS mutations were most common in the T stage IV patients. While there was no statistical significance found comparing the pathological T stage and genetic mutations, the data warrants further investigation with a larger sample size.

 

67.09 Clinical and Epidemiological Factors Associated with Suicide in Colorectal Cancer

Posted on January 26, 2017

T. Pham1, A. Talukder1, N. Walsh1, A. Lawson1, A. Jones1, E. J. Kruse1  1Medical College Of Georgia,Surgery,Augusta, GA, USA

Introduction:  Increased suicidal tendencies among cancer patients have been well documented. To date, there has been no specific examination of suicide rates and factors associated with suicide in colorectal cancer. The aim of this study is to examine suicide incidence and associated factors in colorectal cancer patients from 1973 to 2013.

Methods:  The Surveillance, Epidemiology, and End Results (SEER) Database of the National Cancer Institute was queried to identify patients with colorectal cancer. The study included mortality and demographic data from 1973 to 2013. Comparison data with the general United States population was derived from the Centers for Disease Control and Prevention’s National Center for Injury Prevention and Control using the Web-based Injury Statistics Query and Reporting System (WISQARS). Standardized mortality ratios (SMRs) and their 95% confidence intervals (95% CIs) were calculated, and multivariable logistic regression models generated odds ratios (ORs) for the identification of factors associated with suicide in colorectal malignancy.

Results: Overall, 1347 suicides among 884,529 patients were identified. Of the patients committing suicide, almost half, 1158 (84%), were over 80 years old. There was no statistically significant difference in suicide rate with respect to age, marital status, median household income, surgical intervention, or histologic subtype. Whites were significantly more likely to commit suicide than non-whites ( OR 2.28, 95% CI 1.89-2.75 P< 0.001), and males were significantly more likely than females (OR 5.635, 95% CI 4.85-6.54, P <0.001). Most suicides occurred in patients with distal lesions in either the sigmoid or rectosigmoid junction (P<0.001). Stage at diagnosis did not have a statistically significant relationship to suicide. SMRs for patients with colorectal cancer were 4.24 for females (95% CI, 3.69- 4.86), 1.35 for males (95% CI, 1.28- 1.43), 0.38 for African-Americans (95% CI, 0.28- 0.52), 1.77 for Whites (95% CI, 1.68- 1.87), and 0.90 for other races (95% CI, 0.72- 1.12). 

Conclusion: Identification of evidence-based risk factors associated with suicide among patients with colorectal cancer is an important step in the development of screening strategies and management of psychosocial stressors. Race and gender appear to influence suicide rates in patients with colorectal cancer. Females with colorectal cancer demonstrated approximately four times the suicide rate of the gender-matched population. These results, coupled with further studies and analyses, could be used to formulate a comprehensive suicide risk factor scoring system for screening all cancer patients. 

 

67.08 Transthoracic Versus Transhiatal Esophagectomy: Is there a More Favorable Approach?

Posted on January 26, 2017

M. Berrata3, R. Shridhar2, P. Briceno1, S. Kucera4, A. Patel5, J. Lee1, J. Huston1, K. Meredith1  1Florida State University College Of Medicine/Sarasota Memorial Health Care System,Gastrointestinal Oncology,Sarasota, FL, USA 2University Of Central Florida,Radiation Oncology,Sarasota, FL, USA 3Florida State University College Of Medicine,Sarasota, FL, USA 4Florida State University College Of Medicine/Sarasota Memorial Health Care System,Endoscopic Oncology,Sarasota, FL, USA 5Florida Cancer Specialists,Medical Oncology,Sarasota, FL, USA

Introduction:  Esophageal cancer continues to increase in incidence worldwide. The long-term survival for patients with locally advanced esophageal cancer remains poor despite improvements in multi-modality care over the last several decades. Surgical resection remains piviotal in the management of patients with esophageal cancer.  The myriad of techniques preclude the recommendation of a standard approach to esophageal resection. We investigate the difference in outcomes between the trans-thoracic (TT) and trans-hiatal (TH) approach in esophageal cancer patients undergoing esophagectomy. 

Methods: A prospectively managed esophagectomy database was queried for patients undergoing trans-thoracic or trans-hiatal esophagectomy between 1996 and 2015. Basic demographics, tumor characteristics, operative details, and post-operative outcomes were recorded. Continuous variables were compared using the Kruskal Wallis or the ANOVA tests as appropriate. Pearson’s Chi-square test was used to compare categorical variables. All statistical tests were two-sided and an α (type I) error <0.05 was considered statistically significant. 

Results: We identified 846 patients who underwent esophageactomy with a mean age of 64 ± 10 years, 714 (84.4%) TT and 132 (15.6%) TH. There were 239 (33.5%) patients within TT that underwent minimally invasive approach (MIE) and 63 (47.7%) within TH that underwent MIE.  Post-operative complications occurred in 207 (29.0%) patients in the TT and 59 (44.7%) in the patients who underwent TH p<0.001.  The most common complications in TT vs TH were anastomotic leak: 4.3% vs 9.8% p=0.01; anastomotic stricture 7% vs 26.5%, p<0.001; pneumonia 12.6% vs 22.7% p<0.002; aspiration 1.7% vs 15.9%, p<0.001; wound infection 4.5% vs 10.6% p=0.004; atrial fibrillation 13.6% vs 14.4%, p=0.8; and pleural effusion 3.2% vs 11.4%, p<0.001.  There were 13 (1.5%) mortalities, 11 (1.5%) in the TT and 2 (1.5%) in the TH cohort, p=1. Neoadjuvant therapy was administered in 459 (64.3%) TT and 78 (59.1%) TH patients, p=0.2. R0 resections were comparable amongst groups 679 (95.6%) in TT and 122 (93.1%) in TH p=0.2. However the lymph node harvest was higher in the TT patients 12±8 compared to 9±6 in the TH group, p<0.001 and 18±9 in the MIE TT vs 9±6 in the MIE TH, p=0.001. 

Conclusion: While both TT and TH are acceptable techniques for esophageal resection, the trans-thoracic approach is associated with fewer post-operative complications.  Pulmonary complications which are traditionally believed to be lower in the TH groups were also higher in patients undergoing the trans-hiatal approach. Additionally, patients undergoing TT demonstrated superior nodal harvest which may have implications in oncologic outcomes.
 

67.07 Plantar Foot Melanoma – The Inaccuracy of the Initial Biopsy and Inadequacy of Resection Margins

Posted on January 26, 2017

J. E. Miller1, S. A. Debolle1, T. N. Ballard2, A. B. Durham3, J. H. Kozlow2  1University Of Michigan,Medical School,Ann Arbor, MI, USA 2University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA 3University Of Michigan,Department Of Dermatology,Ann Arbor, MI, USA

Introduction:  The plantar surface of the foot is unique due to its ridged epidermis and ability to undergo hyperkeratosis. It is unclear if melanomas arising on the plantar surface of the foot behave clinically similar to melanomas in other areas of non-glabrous skin, making clinical decision-making and treatment more challenging. The two specific aims of this study were to determine the accuracy of the Breslow depth of the initial biopsy and to determine the incidence of positive microscopic margins following an intended curative excision.

Methods:  In this retrospective study, we reviewed the charts of 103 patients with plantar foot melanoma treated at the University of Michigan from 1997 to 2015. The Breslow depth from the initial biopsy pathology report was compared to the Breslow depth in the final pathology report following either repeat biopsy or definitive surgical excision. These results were compared both in absolute Breslow depth and for changes in Tumor staging. We evaluated the microscopic margin status on the pathology report and used published guidelines to determine if appropriate surgical margins were taken in the intended curative resection.

Results: A total of 46 patients (45.5%) had an increase in Breslow depth compared to their initial biopsy, with 34 (33.7%) having an increase substantial enough to change their tumor staging. A total of 16 patients (15.5%) had positive microscopic margins following an intended curative excision. Patients with stage T3 and T4 tumors had the highest incidence of positive microscopic margins, with 21.4% and 30.0%, respectively, requiring a re-excision. Of the 70 patients treated with surgical margins in accordance with NCCN guidelines, 12 (17.1%) had positive microscopic margins, whereas only 1 (6.3%) of the 16 patients treated with margins larger than guideline recommendations had positive microscopic margins.

Conclusion: The surgical management of plantar foot melanoma depends on the Breslow depth of the tumor. Current practices often use the initial biopsy pathology report to determine Breslow depth of the tumor, however our findings show that these values are often incorrect and frequently under-stage the actual tumor depth. Additionally, clinicians should be aware of the high rate of positive microscopic margins in this area of the body, even when standard guidelines are followed. This information will allow for improved informed shared decision making with patients and will affect the timing of reconstructive procedures.

67.06 Current surgical practice in prevention of lymphedema in breast cancer patients

Posted on January 26, 2017

D. Balaji1, T. Hughes2, A. Chagpar1  1Yale University,Surgery,New Haven, CT, USA 2McPherson Hospital,Surgery,McPherson, KS, USA

Introduction:   Recently, more data has emerged noting that avoidance of IVs, blood pressures and blood draws do not significantly increase lymphedema after breast cancer surgery, while resistance exercise is effective in reducing lymphedema.  We sought to determine surgeons’ practices in preventing lymphedema after breast cancer surgery and factors associated with variation in this.

Methods:   An anonymous survey was posted on the American College of Surgeons’ Communities online platform.  From June 28, 2015 to August 9, 2015, 273 surgeons responded to the survey.  In addition to their demographics and practice patterns, surgeons were asked about their perceptions regarding the prevalence of lymphedema after sentinel lymph node biopsy (SLNB) and axillary node dissection (ALND).  Bivariate analyses using non-parametric statistics were performed using SPSS Ver. 21 software.

Results:  56.4% of respondents were 40-60 years of age; 52.3% had been in practice 11-30 years.  29.7% had solely breast practices; 14.7% were academic, 44.3% in private practice.  85% of respondents felt the risk of lymphedema after SLNB was < 5%; 52.1% felt that the risk of lymphedema after ALND was <10%.  In terms of their routine practice, 49.1% said they advise avoiding ipsilateral blood pressures, 58.6% avoid ipsilateral blood draws/ivs.  Only 3.7% routinely recommended a sleeve to avoid lymphedema, while 21.6% recommended a sleeve for air travel.  31.5% encouraged lifting weights, while 2.2% advised patients to avoid doing so.  Surgeons who were in solely breast-related practices were more likely to routinely encourage lifting weights (53.1% vs. 22.5%, p<0.001) and advocate sleeves for air travel (44.4% vs. 12.0%, p<0.001).  They were also more likely to quote a rate of >20% of lymphedema after ALND (20.5% vs. 7.2%, p<0.001).  There was no significant variation in recommendations regarding avoidance of ivs, blood pressures, or routine sleeve use based on surgeon demographic or practice type or location.

Conclusion:  Despite mounting data that lymphedema can be reduced with weight-bearing exercise, only a third of surgeons routinely recommend this.  There seems to be variation in recommendations to avoid blood pressures and ivs among surgeons, with roughly half routinely recommending to avoid these after lymphadenectomy, but this variation is not mediated by surgeon demographic or practice type.  Consensus guidelines may therefore be indicated regarding appropriate prevention of lymphedema in breast cancer patients.

 

67.05 The Effect of Adjuvant Chemotherapy on Overall Survival in Patients with Synovial Sarcoma

Posted on January 26, 2017

C. C. Vining1, A. J. Sinnamon1, M. G. Neuwirth1, B. L. Ecker1, R. R. Kelz1, D. L. Fraker1, R. E. Roses1, G. C. Karakousis1  1Hospital Of The University Of Pennsylvania,Department Of Endocrine And Oncologic Surgery,Philadelphia, PA, USA

Introduction:
The management of stage I-III synovial sarcoma is primarily surgical with consideration of adjuvant radiation. However, the role of adjuvant chemotherapy (AC) remains less well-defined limited to small institutional series. Using a large national dataset we sought to identify factors associated with receipt of AC and to evaluate impact on overall survival (OS).

Methods:
Patients with stage I-III synovial sarcoma 2004-2012 undergoing resection were identified in the National Cancer Data Base. Patients were excluded if they received any neoadjuvant therapy or had incomplete grade, size, or adjuvant therapy data. Chi-square and multivariable logistic regression was used to identify factors associated with receipt of AC (univariate p-value<0.05 for inclusion in multivariable model). Clinicopathologic factors and adjuvant therapies associated with improved OS were identified with univariate and multivariable Cox proportional hazard modeling and the Kaplan-Meier method, applied to the overall cohort and to subgroups stratified by stage.

Results:
From 2004-2012, 597 patients underwent resection with evaluable data. Median age was 41 (IQR 29-54) and 302 were female. Four-hundred sixteen tumors were high grade, 204 were 5-10cm, and 97 were >10cm. One hundred eighty-four patients received AC, 311 received adjuvant radiation, and 102 received both. Factors associated with receipt of AC in multivariable analysis included age <40y (OR 2.49), high grade pathology (OR 2.04), size (5-10cm OR 2.45; >10cm OR 3.52), and positive margins NOS (OR 5.67). In multivariable analysis, factors significantly associated with worse OS included age>40y (HR 2.57), Charlson-Deyo comorbidity score ≥ 2 (HR 3.18), monophasic histology (HR 2.89), size 5-10cm (HR 2.06), >10cm (HR 2.12), high grade (HR 3.24), positive lymph nodes (HR 15.9), omission of adjuvant radiation (HR 1.64), and macroscopic surgical margins (n=5, HR 8.53); notably, AC was not significantly associated with improved OS. However, when patients were stratified by stage, AC was associated with improved OS among stage III patients but not in lower stage groups. This association remained significant in multivariable analysis (HR 0.59, p=0.037). The stage III group (n=227) was comprised almost entirely of high grade tumors >5cm, as confirmed LN metastasis were rare (n=3). Ninety-eight (43%) of these patients received AC, compared to 24% of stage II (82/339), and 13% (4/31) of stage I.

Conclusion:
In this large national dataset AC in resected synovial sarcoma was associated with improved OS in patients with stage III disease but not in lower stages. Less restricted use of this therapy may be warranted considering it was administered to less than half of these patients.
 

67.04 Survival in DCIS Patients Undergoing Surgery versus Patients Not Undergoing Surgery

Posted on January 26, 2017

P. Singh1, M. Miller2, C. Wang4, D. J. Winchester3, C. Pesce3, E. Barrera3, K. Yao3  1University Of Chicago,Surgery,Chicago, IL, USA 2Memorial Sloan-Kettering Cancer Center,Surgery,New York, NY, USA 3Northshore University Health System,Surgery,Evanston, IL, USA 4Northshore University Health System,Center For Biomedical Research Informatics,Evanston, IL, USA

Introduction:  A clinical trial in Europe is randomizing low-grade ductal carcinoma in situ (DCIS) patients to surgery versus no surgery arms and a similar trial will start soon in the United States. We utilized the National Cancer Database (NCDB) and the Surveillance, Epidemiology, and End Results (SEER) retrospective databases to examine overall (OS) and disease-specific (DSS) survival between patients who underwent surgical excision of DCIS versus those patients who did not undergo excision.

Methods:  The NCDB and SEER databases were queried for low-grade DCIS patients treated from 2004-2011. We examined OS from both databases and DSS from SEER alone and used Cox regression modeling to adjust for patient, tumor and treatment factors. Mean follow-up for the surgery group was 5.6 years and 5.1 years for the no surgery group.

Results: Of 150,479 low-grade DCIS patients from the NCDB, 2,470 (2.0%) were reported to have no surgery and of 17,342 low-grade DCIS patients from SEER, 443 (2.5%) had no surgery. The mean age of the surgery group for NCDB and SEER was 58.8 and 58.4 years respectively and for the no surgery group was 60.4 and 60.8 years respectively. Mean tumor size was 1.5cm and 1.6cm for the NCDB and SEER patients respectively who had surgery, and 1.8cm and 1.5cm respectively for those who did not have surgery. Estrogen receptor was positive in 82.5% and 83.3% of the NCDB and SEER patients who had surgery and 82.1% and 85.8% of the NCDB and SEER patients who did not have surgery. In the NCDB and SEER patients undergoing surgery, 48.3% and 52.8% had radiation therapy versus 16.7% and 7.9% of those not undergoing surgery. Of NCDB patients, 33.1% of the surgery group received hormonal therapy compared to 11.7% in the no surgery group. OS at 10 years for both NCDB and SEER patients was greater for those who had surgery versus those who did not; in SEER, DSS was greater in the surgery group (Table 1). On Cox regression modeling adjusting for patient, tumor and treatment factors, not having surgery was associated with a 2.07 (95%CI: 1.73-2.46, p<0.001) greater risk of death in the NCDB and a 2.05 (95%CI: 1.63-2.59, p<0.001) greater risk of death in the SEER patients. The hazard ratio for DSS was 6.37 (95%CI: 3.8-10.6, p<0.0001) in SEER. Similar findings were found for estrogen receptor-positive patients alone.

Conclusion: OS and DSS were significantly higher in the surgery group versus the no surgery group. Although findings were similar between the two databases, selection bias may account for the survival differences between the surgery and no surgery groups given the retrospective nature of the databases. Future clinical trials will be more definitive in determining survival outcomes in DCIS patients not undergoing surgery.

 

67.03 Patients with Low or High BMI are at Higher Risk for Nipple/Skin Loss After Nipple Sparing Mastectomy

Posted on January 26, 2017

E. M. Urrechaga1, A. Soran1,2, P. F. McAuliffe1,2,3, R. R. Johnson1,2, C. Thomas1,2, M. Bonaventura1,2, G. M. Ahrendt1,2, E. J. Diego1,2  3Magee-Womens Research Institute,Pittsburgh, PA, USA 1University Of Pittsburgh,Pittsburgh, PA, USA 2Magee-Womens Hospital Of UPMC,Pittsburgh, PA, USA

Introduction:

Nipple sparing mastectomy (NSM) has been proven to be oncologically safe with relatively low complication rates. With expanding indications for NSM, a larger population of patients (pts) is undergoing the procedure for therapeutic or prophylactic purposes.  Though it has been established that obesity (Body Mass Index (BMI) >30) increases the risk for complications after NSM requiring reoperation, there is a paucity of data regarding this risk in patients with a low BMI (<18.5). We hypothesize that patients with a low BMI are at higher risk of clinically significant nipple and skin complications requiring a reoperation after NSM compared to patients with a normal BMI.

Methods:  

A retrospective review of a prospectively maintained NSM registry was performed at a single institution from August 2010-June 2016. Clinicopathological information including age, cancer status and stage, BMI, bra cup size, smoking status, incision and reconstruction type, and need for chemo or radiation therapy were recorded. BMI was categorized into 3 groups: low (<18.5), normal-overweight (18.5-30), and obese (>30). Chart review was performed to evaluate need and reason for reoperation.   Fisher’s exact test was performed to evaluate BMI and reoperation rates using STATA 14.1 with significance set at a p-value <0.05.

Results: 

Of 211 pts who underwent 370 NSMs, 6.6% (14/211) had a low BMI, 88.2% (186/211) had normal to overweight BMI, and 5.2% (11/211) were obese (BMI>30). Of 370 NSMs, reoperation was required in 12.4% (46/370): 8.1% (30/370) for nipple/skin necrosis and 4.3% (16/370) for infection. Among pts with low BMI, 21.4% (3/14) required reoperation for either skin or nipple necrosis compared to 16.1% (30/186) in the normal BMI group and 27.3% (3/11) in the high BMI group (p=0.02). In the pts with low BMI, 2 pts suffered bilateral nipple loss. In the pts with high BMI, 1 pt had bilateral nipple loss. 

Conclusion: 

Pts with a low BMI are at higher risk for clinically significant skin or nipple necrosis that may require reoperation compared to those who have a normal BMI. These findings also confirmed a higher risk of skin or nipple necrosis requiring reoperation in the high BMI group. A larger sample would be needed to confirm these results, but this should be taken into consideration when counseling pts regarding surgical risk.
 

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